What simulation do you offer your residents?
Answer: At Stanford we have a long tradition in Simulation starting as early as the late 1980’s when one of the very early simulation centers was started at the Palo Alto VA. I remember my day as a resident in 1992 at the Anesthesia Crisis Resource Management course where I learned some key skills that I still use today everyday. These lessons include call for help, delegate and confirm, avoid fixation errors, mobilize all available resources, anticipate and plan for problems, and know your environment.
Today, we have a post residency fellowship in Simulation and one of our residents on the FARM research track, Ankeet Udani, is focusing on medical simulation. Stanford has a large new space for simulated and immersive learning at the Li Ka Shing Center for Learning and Knowledge, a state of the art facility which will allow us to further expand simulation education. http://cisl.stanford.edu/
Dr. Sara Goldhaber-Fiebert has just finished compiling an inventory listed below of Stanford Aneshesia resident simulation activities.
Anesthesia Newbie Course (CA-1 July, 1 full day)
Contact: Dr. Steve Howard, showard@stanford.edu
Brief Description: This course provides exposure to the basics of anesthesia and familiarity with Stanford equipment before caring for real patients as an anesthesia resident. Small groups go through a half day simulation session where they set up the room and perform an anesthesia machine check. They are then presented with two types of general anesthetic inductions (e.g., non-full stomach and full stomach) as well as common physiologic perturbations. This gives new residents the opportunity to “slow the process down,” ask questions, and discuss with faculty. The other half of the day is spent practicing procedural skills on mannequin models.
Quote from resident: The “newby course” was a great introduction to feeling like an anesthesiologist since I had not been in an OR for more than 10 months. Being able to be hands-on with everything in the room was very helpful for the upcoming weeks of anesthesia residency.
Anesthesia Crisis Resource Management Series (Includes 1 full day each year of residency in groups of 4-5: ACRM 1, ACRM 2, ACRM3)
Contact: Dr. Sara Goldhaber-Fiebert, saragf@stanford.edu
Brief Description: In a realistic-feeling operating room setting with mannequin patients, anesthesia residents are given the opportunity to be “it” — leader and decision maker — as the attending anesthesiologist. For each ACRM course, 4-5 residents spend the
entire day (about 8 hours) participating in intensive simulation scenarios, each followed by an in-depth debriefing, and are taught by 2-4 faculty members. Residents rotate through different roles in the simulation scenarios (primary anesthesiologist, responding anesthesiologist, scrub tech, real-time observer in debriefing room) but all debrief together. These challenging cases get everyone’s adrenaline flowing in a safe and fun learning environment. While reviewing medical concepts and technical skills, the debriefings also focus on principles of Crisis Resource Management as outlined in the overview above.
Quotes from residents: “The ACRM1 course was one of the best educational aspects of my residency training to this point. Working in a team model to respond to crises is not common in the OR on a daily basis, so seeing how you react in simulation is an eye-opening experience. I’m proud to say, within the next week I was met by a real situation in the OR in which I was able to pull what I had learned in simulation to help guide me (and my patient) through safely.
“Terrific scenarios. They are a wonderful opportunity to experience intense situations and to learn from our mistakes in a safe way. “
Flexible fiberoptic intubation course (CA-1, for one full day every year)
Contact: Dr. Vladimir Nekhendzy. nek@stanford.edu
Brief Description: This full-day fiberoptic airway skills course includes introductory didactic lectures on the “anatomy” of the fiberoptic scope, basic and advanced techniques of fiberoptic intubation, and preparation of a patient for an awake fiberoptic intubation. The hands-on training begins with practicing on specially designed models to allow familiarity with the necessary motor and visual skills involved in manipulating a fiberoptic scope. Residents progress to navigating the scope into a mannequin’s trachea through both oral and nasal routes. Finally, advanced techniques of flexible fiberoptic intubation and fiberoptic-assisted airway exchange are covered. Taught by multiple Stanford anesthesia faculty, a high instructor to learner ratio allows
residents to practice these skills at stations in small groups.
Difficult airway course (CA-2,3 for one full day every year)
Contact: Dr. Vladimir Nekhendzy, nek@stanford.edu
Brief Description: This 10 station difficult airway workshop includes integrated didactic lectures, case presentations, and mostly hands-on training on the mannequins. All mainstream alternative airway management devices and techniques are covered in a systematic fashion. Extensive use of video monitors and a high instructor to trainee ratio allow each faculty to supervise two learners simultaneously, which results in rapid acquisition of new skills. The course accommodates max 60 people.
OBSim (Residents attend on average one of these 2-hour sessions during residency)
Contact: Dr. Steve Lipman, steve.lipman@stanford.edu
Brief description: Multidisciplinary obstetric crisis team training. At OBSim we take a two-pronged approach to simulation efforts. Half the year, we run sessions at CAPE (Center for Advanced Pediatric and Perinatal Education) focusing on didactic medical education using a controlled simulated environment to enhance retention of medical knowledge, while addressing elements of team communication and management skills. The other half of the year, we turn our attention to In-Situ Labor and Delivery Room Drills where we focus more on systems issues and teamwork. In the past few years, we have run sessions including: Stat cesarian section, Eclamptic seizure, Massive hemorrhage, etc.
Quote from resident: “I was able to participate in the on site OB simulation that coordinated a simulation between labor and delivery nurses, anesthesia techs, scrub techs, OB residents/attendings, and anesthesia resident/attendings. It was a real life scenario and conducted in real time. I learned the logistics of treating “while on the go”, meaning pushing drugs, developing an anesthetic plan, and hemodynamic treatment while transporting from the delivery room to the operating room. Just recently I was on my second OB rotation in which a real life case was very similar to the one we had in OBSim. After all was said and done the OB resident looked up at me and said ‘this was just like the sim’. We were better prepared, had decreased transport times, and shorter delays due to our training in simulation.”
NeoSim (Residents attend one 4-hour session during residency and earn Neonatal Resuscitation Provider [NRP] certification for two years)
Contact: Dr. Steve Lipman, steve.lipman@stanford.edu
Brief description: An immersive, simulation-based version of the NRP course currently offered by the American Academy of Pediatrics (AAP). Created by Lou Halamek, a Neonatologist at Lucile Packard Children’s Hospital who serves on the board of AAP. Because ~ 10% of newborns require some degree of resuscitation immediately after delivery, residents on the obstetric anesthesia rotation have been attending NeoSim since 2003.
Quote from resident: I learned a lot during the simulation courses at the VA and now at CAPE. It’s like having really scary life-or-death experiences that I’ll never forget, without consequences.
Peds Anesthesia Sim (Residents attend 2 or 3 ninety-minute sessions during residency.)
Contact: Dr. Michael Chen, michael1@stanford.edu
Brief Description: It is frequently said that “infants are not just small adults.” So how do you train future anesthesiologists to handle pediatric emergencies? The answer is Pediatric Anesthesia Simulation. These short but realistic sessions will expose residents to the most common pediatric emergencies (laryngospasm, difficult airways, malignant hyperthermia, hemorrhage, cardiac arrest, etc.) The scenarios take place in the operating room and usually include nurses, scrub techs, and surgeons.
Central Line Workshop (CA-1 summer, 3 hours)
Contact: Dr. Fred Mihm, fmihm@stanford.edu
Brief description: This course exposes new CA1 residents to the use of ultrasound in placing central venous lines, with an emphasis on the safest, line via the internal jugular vein. The training is designed to introduce residents to the ultrasound machine (buttons/knobs), acquiring optimal images, central line kits/components (triple lumen and introducer lines). Particular attention is placed on using the ultrasound probe with needle guide in order to actually visualize vessel puncture and to minimize complications.
Quote from Resident: “This was like being at Disneyland!”
ICU IMPES: Improving Management of Patient Emergency Situations (4 hours for anesthesia residents on VA ICU rotation)
Contact: Dr. Geoff Lighthall, geoffl@stanford.edu
Brief description: IMPES provides team simulation training focusing on caring for critically ill ICU patients. Debriefings of scenarios focus on medical knowledge and implementation of best practices, as well as the impact of Crisis Resource Management (CRM) principles on patient care. Given the many different caregivers who practice in the ICU, this multidisciplinary team training includes not only anesthesia residents, but also ICU fellows, residents from medicine and surgery, nurses, respiratory therapists, and pharmacists.
Quote from resident: “High point of ICU rotation”
Ultrasound guided Regional anesthesia workshop (Open to all residents, annually 6 hours)
Contact: Dr. Lindsey Vokach-Brodsky, lindsey.vokach-brodsky@stanford.edu
Brief description: This regional workshop consists of rotating through 10 small-group stations, each with a brief didactic presentation followed by hands-on practice using ultrasound. The stations include all the commonly performed ultrasound-guided blocks, such as supraclavicular, sciatic, and femoral. Each year, new techniques are integrated into the workshop, such as ultrasound-guided neuraxial block and Transversus Abdominus Plane (TAP) block. By including a specially-dissected cadaver, live models, and ‘stickable’ models, this workshop provides review of the relevant anatomy as well as practice of the hand-eye coordination necessary for each ultrasound-guided regional block.
Additional Courses and Resources
—-Procedural Skills lab at VA Palo Alto
—-Mock Code simulations (unannounced) run at VA Palo Alto
—-Hemorrhage Drills on various services at Stanford Hospital
Simulation courses for residents under Development include:
—-TEE Simulator and Echo Curriculum: Dr. Daryl Oakes, doakes@stanford.edu
—-Cardiac Surgery combined team simulations: Dr. Steve Howard, showard@stanford.edu
—-Refresher Courses annually: Dr. Sara Goldhaber-Fiebert, saragf@stanford.edu
—-Pediatric Anesthesia Refresher Workshop: Dr. Michael Chen, michael1@stanford.edu
—-Double Lumen Tube placement: Dr. Vivek Kulkarni, vivek.kulkarni@stanford.edu
Also please keep in mind that most people perceive simulation as mannequin based scenarios, but simulation could be something as simple as discussion of a case and its management in a way that is realistic to the learner.